Introduction
Small Fiber Neuropathy (SFN) is a type of peripheral neuropathy characterized by damage to the small unmyelinated C fibers and thinly myelinated Aδ fibers. These small fibers are responsible for transmitting pain and temperature sensations, as well as autonomic functions such as heart rate, blood pressure, and sweating. Unlike large fiber neuropathies, SFN primarily affects the skin, leading to symptoms that can be quite debilitating despite the absence of muscle weakness or loss of large fiber-mediated sensations.
Symptoms of Small Fiber Neuropathy
The symptoms of SFN can vary widely but typically include:
- Pain: Often described as burning, stabbing, or electric shock-like in nature.
- Paraesthesia: Abnormal sensations such as tingling or prickling.
- Allodynia: Pain from stimuli that do not normally provoke pain.
- Autonomic Symptoms: Including abnormal sweating, digestive issues, and cardiovascular problems.
Diagnosis of Small Fiber Neuropathy
Diagnosing SFN involves a combination of clinical evaluation, patient history, and specific tests. Key diagnostic tools include:
- Skin Biopsy: A small sample of skin is taken to quantify the density of nerve fibers. Reduced nerve fiber density is a hallmark of SFN.
- Quantitative Sensory Testing (QST): Measures the threshold for detecting sensations such as temperature and vibration.
- Autonomic Function Testing: Assesses the function of the autonomic nervous system.
Causes of Small Fiber Neuropathy
SFN can be caused by a variety of factors, including genetic mutations, metabolic disorders, infections, and autoimmune diseases. One significant category of causes includes toxic exposures.
Toxic Causes of Small Fiber Neuropathy
Industrial Agents
Acrylamide: Used in industries such as dye, paper, plastic, and adhesive manufacturing, as well as in water processing. Acrylamide is toxic to nerve terminals and can lead to a length-dependent pansensory-motor polyneuropathy with prominent sensory ataxia. Chronic exposure results in skin irritation, hyperhidrosis, and significant peripheral neuropathy.
n-Hexane and ‘Glue-Sniffing’: n-Hexane is a solvent used in glue and textile manufacturing. Recreational inhalation, known as 'glue-sniffing,' can cause a distal sensorimotor neuropathy characterized by progressive sensory symptoms and weakness. Onset can be acute or insidious, depending on the exposure level. High doses can result in significant conduction slowing, conduction block, and temporal dispersion in nerve conduction studies.
Organophosphates: These are commonly used as pesticides and insecticides. Organophosphate poisoning can lead to a neuropathy presenting as distal numbness, paraesthesiae, cramping, and weakness with bilateral foot drop. The onset typically occurs around three weeks post-exposure, and the neuropathy is often mild, predominantly affecting motor function without significant sensory disturbance.
Heavy Metals
Arsenic and Thallium: Exposure to arsenic and thallium can lead to sensory-predominant neuropathies with symptoms such as hyperkeratosis and Mees' lines on the fingernails. These metals cause a rapid progression of neuropathy, often presenting as acute or subacute sensorimotor neuropathy resembling Guillain-Barré Syndrome (GBS).
Lead: Lead poisoning results in a predominantly motor neuropathy with significant distal weakness. It is often associated with other systemic symptoms such as abdominal pain and cognitive disturbances.
- Mercury: Exposure to mercury, particularly in industrial settings or through contaminated food sources like fish, can lead to sensory neuropathy. Symptoms include distal paresthesia and pain.
Please note there are numerous heavy metals linked to neuropathy.
Chemotherapy Drugs
Certain chemotherapy agents are known to cause peripheral neuropathy, including SFN. These include:
Platinum Compounds: Drugs like cisplatin and oxaliplatin can cause a sensory neuronopathy with symptoms such as sensory ataxia and paraesthesiae. Oxaliplatin, in particular, can lead to an acute neural hyperexcitability syndrome.
Taxanes: Paclitaxel and docetaxel commonly induce painful sensory neuropathies. Patients may also experience acute arthralgia and myalgia.
Vinca Alkaloids: Vincristine is associated with distal weakness and sensory symptoms, often accompanied by autonomic involvement.
Recreational Drugs and Alcohol
Nitrous Oxide: Chronic use of nitrous oxide, often recreationally, can cause a sensory-predominant neuropathy with significant distal motor weakness and autonomic dysfunction.
Alcohol: Chronic alcohol consumption can lead to a slowly progressive neuropathy with predominant sensory involvement. This neuropathy is often multifactorial, with both direct toxic effects and nutritional deficiencies contributing to the condition.
Look out for my posts on how to repair nerves after they are exposed to toxins.